Dr. Amr Gaafar
Obstetrics and Gynecology consultant
Alexandria university
Founder and director of Continental center for women’s healthcare (Smouha, Alexandria and Sheikh Zayed, Cairo, Egypt).
Co-Founder and treasurer of Middle Eastern Society for Adolescent and Pediatric Gynecology (MESPAG).
PCOS is a public health concern and optimal management is not achieved.
Nature gifted us with great solutions to our problems.
A better future for PCOS cases is here.
The future is myo-inositol.
Inositol is a sugar made in the body and found in foods
myo-inositol and D-chiro-inositol are the most
common forms found in supplements.
myo-inositol is naturally present in both animal and
plant cells (as a free form or in phospholipids)
Backbone for numerous secondary messaging signaling
Essential for proper glucose metabolism.
Directly involved in cell growth and in reproduction physiology.
During a physiological menstrual cycle, signals from the hypothalamus–pituitary– gonadal (HPG) axis promote the progression of folliculogenesis through the stimuli of FSH and LH.
Inositol cascade is primarily involved in the signaling of insulin and gonadotropins.
In 2018 ESHRE guidelines, it was considered experimental in PCOS management.(1)
In 2023 ESHRE guidelines, myo-inositol became an
evidence-based recommendation.(2)
ESHRE 2018
ESHRE 2023
All living cells contain myo-inositol phospholipids
in their membranes
Human diet from either animal and plant sources contain
myo-inositol.
Now let’s play and guess which is a good source
of myo-inositol
Look for seeds and fresh fruits/vegetables
Leafy vegetables are poor in myo-inositol
Was once considered to belong to the vitamin B family
Even if you don’t know its values, your body can’t ignore it.
Good absorption and availability
Nearly 99.8% of ingested amount is absorbed.
Normally, the circulating fasting plasma
myo-inositol concentration = 30
µM.
Disturbed Inositol metabolism is associated with insulin-resistance.
myo-inositol supplementation → insulin-mimetic effects
in DM and PCOS models.Low concentration predicts long-term DM microvascular complications.
myo-inositol is documented human
subjects.(3)Associated with improvement in:
Hyperinsulinemia.
Metabolic parameters.
Hyperandrogenism.
Ovarian function.
Ovulation induction.
Oocyte quality.
Embryo quality
myo-inositol supplementation seems to be a simple,
safe and effective first-line treatment for women with PCOS.(3)
Main mechanism of action:(3)
Improving insulin sensitivity of target tissues,
Refreshing the reproductive axis, and
Better hormonal functions (reduction of clinical and biochemical hyperandrogenism and of dislipidemia).
Improved insulin peripheral sensitivity and insulinemia.(3)
Leaner anthropometric measurments (after 16 weeks or more of treatment).(3)
Hormonal parameters:(3)
↓ LH, FSH,and testosterone circulating levels, and
↑ SHBG, estrogens and progesterone circulating levels
Restore spontaneous ovarian activity
↑ Fertility
Cardiovascular parameters:(3)
↓ systolic and diastolic blood pressure,
↓ plasma triglycerides,
↑ HDL cholesterol,
↓ LDL and total cholesterol concentrations.
A meta analysis revealed that effects of
myo-inositol supplementation trespassed achieving
conception.(4)
Interestingly, myo-inositol proved to be a
significant supporter of physiological gestation as well
fertility
myo-inositol supplementation was associated with
successful ovulation and restoration of regular cycles.
Additionally, significantly lower odds of GDM was seen in
patients who received myo-inositol.
Encouraging data from clinical trails of
myo-inositol have been consistently published
A 2014 review provided level Ia evidence of significant improvements in hormonal and reproductive aspects of PCOS cases.(5)
Not only abundance, but balance
In PCOS cases, an imbalance between Inositol isomers (mainly myo- and chiro-inositol) leads to a reduction in insulin and FSH signaling.(6)
A myo- to chiro-inositol ratio of 40:1 is thought to be physiological for most tissues
myo-inositolPre-treatment of myo-inositol is a very new method
that was evaluated in multiple small studies to manage poor ovarian
response in assisted reproduction.
Increasing evidence indicates that inositols play a vital role, namely in oocyte and spermatozoa development.(6)
Via both petentiated signaling and appropriate glucose for growth maturation.(7)
myo-inositol mediates the granulosa
response to FSH stimuli.(7)It also plays a crucial role in determining oocyte maturation.(7)
myo-inositol (in PCOS cases) = proper glucose
available for growing oocytes.(6)myo-inositol during ARTIn both PCOS and non-PCOS women, with myo-inositol
supplementation during ART:
Lower amount of gonadotropins required
Better oocyte quality and maturation
Healthier embryo development, and
Significantly higher rate of successful pregnancies.
Recent studies further empower myo-inositol as a
competitive insulin sensitizer.
Direct comparative studies vs. Metformin were conducted
A RCT reported that while improvements in
anthropometric measurements were noted with both
myo-inositol and metformin, the magnitude of improvement
was comparable between the two treatments.(8)
A 2023 meta-analysis concluded that both are equally beneficial in improving metabolic and hormonal parameters.(9)
In ART: A 2022 study reported that
myo-inositol was associated with significantly
better outcomes in PCOS women receiving
antagonist cycles.(10)
myo-inositol was reportedly
safer than Metformin.
Adverse events were 5 times more common with Metformin compared
to myo-inositol.(11)
With Metformin: abdominal pain, lactic acidosis, and generalized weakness.
With myo-inositol: nausea, mild diarrhea, and
menorrhagia.
Haven’t she heard about myo-inositol?
Coenzyme Q10 (CoQ), is an endogenous lipophilic
quinone.
CoQ10 supplementation was linked to:
Greater response to ovulation induction.
Decreased odds of fetal aneuploidy.
Lower cycle cancellation rate.
Higher odds of a clinical pregnancy.
Even in women older than 35 years, CoQ10 is associated
with:(12)
Larger quantity and better quality of oocytes.
Optimized oxidative metabolism of follicular fluid.
Boosted mitochondrial function of oocytes.
Better odds of a successful pregnancy.
myo-inositol is not the only supplement with growing
supporting evidence in PCOS.
Methylfolate is now believed to be a superior
approach to folic acid supplementation.
Supplementation with methylfolate is as effective as
treatment with folic acid.
However, unlike folic acid, methylfolate is an
active compound and doesn’t need enzymatic transformation.
This is why methylfolate is not affected by
functional polymorphisms in Methylenetetrahydrofolate reductase (MTHFR)
gene.
MTHFR gene mutation can cause infertility and/or recurrent
pregnancy loss if methylfolate is not supplemented.
myo-inositol and methylfolate supplementation
with required doses.It’s myo-inositol, sweet and discreet,
Found in beans, fruits, and whole grains you eat.
It whispers to cells, “Let insulin in,”
And helps ovaries get back to their spin.
No medals, no thanks, not even a clap—
Just hiding in food like a watchful champ.
It helps with the sugar, the cycles, the skin—
But no one says, “Hey! That’s what helped me win!”
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